Comprehensive Guide to Nutrition Intervention and Therapeutic Diets in Healthcare

Comprehensive Guide to Nutrition Intervention and Therapeutic Diets in Healthcare

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  NUTRITION INTERVENTION: Food andNutrient Delivery
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  LESSON OBJECTIVES • Atthe end of the lesson, you should be able to demonstrate understanding of: – What nutrition intervention (NI) and nutrition prescription are – What dietary modification is – The routine diets used in the hospital setting – Applications of modified diets in the hospital setting – Medical food supplements
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  INTRODUCTION • Nutrition Interventions(NI) – They are actions taken to treat nutrition problems by resolving the etiology and/or reducing/managing the related signs and symptoms – It involves two steps: planning & implementation – Nutrition intervention, whenever possible, should target the etiology identified during the assessment step – When the registered dietitian (RD) cannot treat the etiology of the nutrition diagnosis (ND) directly, the treatment should focus on reducing/managing the signs & symptoms of the diagnosis – The planning phase of the NI needs the RD, client and others to collaborate and identify GOALS that will signify success of intervention. A significant part of the plan is the nutr prescription
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  INTRODUCTION • Pt-centred goalsare set first & then implementation begins • Nutrition interventions include – Food & nutrition therapies, nutrition education, counselling, or coordination of care like providing referral to for financial or food resources • Nutrition Prescription – A detailed description of the nutrient needs of a particular client – Typically, it includes recommended needs of energy, protein, and fluid but may also include nutrients pertinent to the client’s condition such as sodium needs in hypertension, carbohydrate needs in diabetes etc. – It’s written by RD after diagnosing the nutrition problems
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  MODIFICATIONS OF THE NORMALDIET • Normal nutrition is the foundation on which therapeutic diet modifications are based • Regardless of the type of diet prescribed, the purpose of the diet is to supply needed nutrients to the body in a form it can handle • Therefore, therapeutic diet (dietary modification) ‒ Refers to the changes made to a normal diet to supply the various nutrient needs of the body in disease states. ‒ It is a normal diet, qualitatively & quantitatively, modified as per the patient's special need & in line with the general principles of meal planning ‒ It is the CORE of dietetic practice and requires enormous skills since no two situations requiring dietary intervention is exactly the same 5
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  QUESTION – ASSIGNMENT • Innot more than 1 page, write on the principles of meal planning. • SUBMISSION DATE: Tuesday, 30th August, ’22 via email: jasare@uhas.edu.gh
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  MODIFICATIONS OF THE NORMALDIET ‒ Modern dietetic practice have long moved from a period where standard dietary advice were given to standard disorders to a period where patients are now encouraged to be actively involved in their own health care management as well as take part in the decision making process. ‒ The role of a registered dietitian here becomes the “ENABLER” i.e. someone who helps people to make appropriate dietary changes, NOT the “DICTATOR” i.e. telling people what to do. 7
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  DIET THERAPY • Itmeans the use of diet (food and drink) not only in the care of the sick, but also in the prevention of disease & the maintenance of health • Diet therapy is accomplished by changing the patient’s normal diet in order to meet the altered requirements resulting from disease or injury • Therapeutic diets are normally requested by a doctor attending to a patient in the hospital, and are planned & prescribed by registered dietitians 8
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  OBJECTIVES OF DIET THERAPY/THERAPEUTICDIETS • To maintain a good nutritional status • To correct nutrition deficiencies or surplus • To afford rest to the whole body or to specific organs affected by disease • To adjust the diet to the body’s ability to metabolize the nutrients during a disease state. E.g. CHO modifications in DM • To bring about changes in body weight whenever necessary 9
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  FACTORS TO CONSIDERIN PLANNING THERAPEUTIC DIETS • The underlying disease condition which needs a change in diet • The possible duration of the disease • The factors in the diet which must be altered to overcome the disease condition • The patients’ tolerance for food by mouth • Patients economic status, food preferences & occupation 10
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  SOME ROUTINE HOSPITALDIETS The Diet Manual • Contains all hospitals’ diets • Describes the diet, rational for its use, foods allowed/not allowed, nutritional adequacy and sample menu • Approved by hospital administration, physician, nursing and clinical dietician • Different facilities have different diet manuals 11
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  SOME ROUTINE HOSPITALDIETS 1. The Regular Hospital Diet • Aka General Diet, House Diet or Routine Diet ‒ No restrictions & used when the client’s medical condition does not warrant any limitations ‒ It approx. provides 1600 to 2200 kcal and usually contains 60 to 80 g protein, 80 to 100 g fat and 180 to 300 g of carbohydrate ‒ Although there are no particular food restrictions, some facilities have instituted regular diets that are low in saturated fat, sugar & salt to follow the dietary recommendations for the general population ‒ Should provide a well-balanced diet capable of maintaining a good nutritional status ‒ Recent developments in health care food service include use of “room service” similar to hotel room service model 12
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  SOME ROUTINE HOSPITALDIETS 2. NPO (nil per os) • Patients are put on this diet prior to surgery or a diagnostic test so that nothing is in the GI tract 13
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  CLASSIFICATION OF MODIFIED/THERAPEUTIC DIETS 14 MODIFIED DIETS CONSISTENCY 1.Liquid Diet 2. Soft diet 3. Mechanical soft diet 4. Pureed diet 5. Bland diet NUTRIENT CONTENT 1. High/low fiber 2. Low protein 3. Na+ restricted diet 4. Low fat diet 5. High potassium diet QUANTITY 1. Weight- reduction diet 2. High- calorie diet SPECIAL METHOD OF FEEDING 1. Enteral (tube feeding) 2. Parenteral (intravenous infusion)
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  MODIFICATIONS IN CONSISTENCY NORMAL DIET- •A normal diet is defined as one which consist of any and all food eaten by the person in health. • It is planned keeping the basic food groups in mind so that optimum amounts of all nutrients are provided. • When the patient is hospitalized or at bed rest, a reduction of 10% (activity factor of 1.1) in energy intake should be made. 15
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  MODIFICATIONS IN CONSISTENCY 1. LIQUID(FLUID) DIETS- • Consist of foods that are liquid at room temperature & are used in; – febrile states (acute fever) – post-operative conditions or whenever the patient is unable to tolerate solid foods. • Liquid diet are of two types depending upon nutritional adequacy- – Clear liquid (fluid) diet – Full liquid (fluid) diet 16
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  MODIFICATIONS IN CONSISTENCY: CLEARLIQUID DIET 17 • CONSIST OF ONLY CLEAR LIQUIDS – The diet is free from any solids, even those found in milk. – The clear liquid diet is inadequate in all nutrients & use only for 1-2 days. It may be high in simple sugars & need to be modified for diabetic patients. • Use – as the first step to restarting of oral feeding after surgery or abdominal procedure – to prevent dehydration & relieve thirst – to replace fluid & electrolyte in people with severe diarrhoea or acute vomiting • AMOUNT OF FLUID GIVEN - initially 40 - 80ml/hour, which is then gradually increased to 100-120 ml/hr. • Average clear liquid diet contains only 500-600 kcal, 5 to 10 g protein, 120-130 g CHO & min fat FOODS INCLUDED:- • Fruit juices w/o pulp– apple/grape juices • Cereal water - barley, arrowroot water, • Soups - clear soups, fat-free broths • Beverages - tea, coffee with lime & sugar (no milk), lime juice, coconut water, sugarcane juice • Flavored gelatin (Jell- O)
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  MODIFICATIONS IN CONSISTENCY: FULLLIQUID DIET 18 • A diet consisting of all beverages allowed on clear liquid diets with addition of milk, ice cream and liquid nutritional supplements. – prescribed to individuals who are unable to chew, swallow or tolerate mechanical soft diet or solid foods. – given after clear liquid diet & before starting solid diet (transition between clear liquids & solid food) – composed of foods that are liquid at room temperature. – It is free from cellulose & irritating condiments or spices. – It is well planned to meet most of the RDA’s – prescribed during acute infections, gastritis, after surgery, & for people too ill to eat solid foods • Diet provides - approx. 1500-2000 kcal, 55-65 g protein and adequate minerals and vitamins FOODS INCLUDED- • Cream soups, whipped potatoes. • Milk shakes, plain ice cream, yoghurt, custard. • Oat meal with milk. • Soya-milk, complan, Ensure and Boost
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  MODIFICATIONS IN CONSISTENCY: 2.SOFT DIET 20 • Soft diet is a nutritionally adequate diet. – It is soft in consistency & easy to chew – Made up of simple, easily digested foods – It is moderately low in cellulose • Prescribed in- conditions where mechanical ease in both eating or digestion are desired. – Given during - acute infections, GI disorders, chewing problems & after surgery. • SOFT DIET SUPPLIES- 1800-2000 kcal, 55-65g protein. FOODS INCLUDED- • Refined cereals • Washed pulses- form of soups & in combination of cereals & veggies. • Milk & milk products. • Eggs & lean meats. • Soft fruits like papaya, banana, mango etc. • Fats like butter, cream, vegetable oils. • Salt & sugar in moderation. FOODS TO AVOID- • Spicy, highly seasoned & fried foods • Raw vegetables & fruits. • Whole grain cereals & their product • Dried fruits & nuts.
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  MODIFICATIONS IN CONSISTENCY: 3.MECHANICAL SOFT DIET 21 • Also called dental diet. Used when there are chewing & swallowing problems • It is for people with poor dental conditions, missing teeth or no teeth or a condition called dysphasia • It includes foods which are easy to chew & swallow. • No restriction on seasoning or method of preparation. • Food may be modified by: – mechanical processing such as mashing, grinding, blenderizing, or chopping.
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  MODIFICATIONS IN CONSISTENCY: 4.PUREED DIET 22 • Changes the regular diet by pureeing it to a smooth liquid consistency • Pureed foods are soft, moist & smooth. They have the look & texture of a pudding and they hold together. They should not be lumpy, thin or runny. • Indicated for people with wired jaws extremely poor dentition in which chewing is inadequate • It’s also for people with chewing or swallowing difficulties or with dysphasia condition • Avoid nuts, seeds, raw vegetables and dried fruits, hard candy. Allowed: boneless fish, all smooth cooked cereals, pureed pancake
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  MODIFICATIONS IN CONSISTENCY: 5.BLAND DIET 23 • A diet consisting of foods that are generally soft, low in fiber, cooked rather than raw & not spicy. • In effect it includes foods that are mechanically, chemically & thermally non irritating • PRESCRIBED FOR: – individuals suffering from gastric or duodenal ulcers, gastritis, & ulcerative colitis. FOODS INCLUDED: • Milk & milk products. • Refined cereals & rice. • Cream, butter • Cooked fruits & vegetables without peel & seed. • All egg preparations except omelet's & fried eggs. FOODS AVOIDED: • Strong tea, coffee, alcoholic beverages, condiments & spices. • High fiber foods & hot soups & beverages. • Fried foods.
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  MODIFICATIONS IN NUTRIENT CONTENT •The nutrient content of the diet is modified to treat deficiencies, change body weight, or control diseases such as hypertension, dyslipidemia, diabetes etc. • Fiber, sodium & fat content are modified in some conditions. 1. MODIFICATION IN FIBER:- bulk & fiber has been used for all indigestible polysaccharides which remains after digestion of food. • Fiber can be modified in two ways: ‒ High fiber diet: used to prevent & treat constipation & high cholesterol. Prescribed in obesity to increase bulk (volume) of food ‒ Low fiber diet: prescribed during acute infections of GI tract, e.g. severe diarrhoea, ulcerative colitis. Fruits & veggies without skin 24
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  MODIFICATIONS IN NUTRIENT CONTENT 2.HIGH-CALORIE DIET:- This is a normal diet with an increase in the calorie level to 2000 or more. If appetite is poor, small servings of highly reinforced foods are given. • The diet may be modified in consistency and flavour, according to specific needs. • Excessive amounts of foods that have a low calorific value and fried foods which disturb the appetite should be avoided. • This diet is prescribed for conditions such as: ‒ Burns ‒ Fever ‒ Hyperthyroidism ‒ Malnutrition (underweight) 25
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  MODIFICATIONS IN NUTRIENT CONTENT 3.LOW-CALORIE DIET:- This diet controls calories (carbohydrates, proteins and fat) intake in balanced amount to meet the nutritional needs & control blood sugar and weight. • This is a normal diet with energy values reduced to 1500 or 1200 calories. ̶ Protein levels should be at 65 to 100g. ̶ Supplements of Vitamin A and thiamine are usually required for diets below 1000 calories. • This diet is prescribed for reducing body weight in: ‒ Diabetes mellitus ‒ Cardiovascular diseases ‒ Hypertension ‒ Gout ‒ Preceding surgery 26
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  MODIFICATIONS IN NUTRIENT CONTENT 4.HIGH PROTEIN DIET:- This is a diet which is high in plant & animal proteins • Used to treat malnutrition or to increase muscle mass • High protein diet of ≥ 2 g/kg body wt may be prescribed for a variety of conditions like: ‒ Burns ‒ Fever ‒ Hyperthyroidism ‒ Post surgery 27
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  MODIFICATIONS IN NUTRIENT CONTENT 5.LOW PROTEIN DIET:- This is a diet in which intake of protein is reduced • This diet is often prescribed to people with kidney or liver disorders • Low protein diets are usually prescribed for conditions like: ‒ Hepatic encephalopathy ‒ Acute and chronic renal failure (no dialysis) ‒ In-born errors of metabolism (due to lack of enzymes of the urea cycle) 28
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  MODIFICATIONS IN NUTRIENT CONTENT 6.FAT CONTROLLED DIET:- This type of diet regulates the amount and type of fat allowed • Limits fat to 50 g or no more than 20-30% calories derived from fats with about 7% from saturated fats and approximately 250 mg cholesterol • Usually fat controlled diets are prescribed for; ‒ Diseases of the Gall bladder, Liver & pancreas ‒ Atherosclerosis ‒ Dyslipidemia ‒ Myocardial infarction 29
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  MODIFICATIONS IN NUTRIENT CONTENT 6.LOW SODIUM DIET:- The mineral content of the diet may also be modified. Four levels of sodium restriction are used — 250, 500, 1000 and 2400 mg. • The diet excludes excess salty foods and salt in cooking and at the table • This diet is used both to prevent and treat oedema • Therefore, it is prescribed for; ‒ Congestive cardiac failure ‒ Hypertension ‒ Liver and renal diseases 30
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  SUMMARY OF NUTRIENT MODIFICATIONIN DISEASED STATES 31 DISEASE NUTRIENT MODIFICATION Atherosclerosis Fat controlled, low cholesterol diet Kidney disease Protein, sodium & fluid restricted diet Anaemia, high fever, Injury High protein, Iron, folate & B12 rich diet Hypertension, CVD Sodium-restricted diet Diabetes Calorie controlled (CHO, Protein, fats) diet Hepatic coma Low protein diet Underweight High-calorie, high protein diet
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  MODIFICATIONS IN QUANTITY •The quantity of food served to the patient needs to be modified to:- ‒ check tolerance, ‒ control nutrient levels (i.e., CHO, Prot. & Fats) ‒ control weight • Example - in a diabetic diet, the quantity of CHO in each meal is as important as the quantity of CHO consumed in a day (portion control is used at mealtimes as prescribed by RD using exchange list for meal planning) 32
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  MODIFICATIONS IN FEEDING METHOD ❖Enteral feeding - EN is provision of liquid formula diet delivered via a feeding tube. It’s the method for patients with a functional GI tract who require Nutrition Support – Tube feedings are used for people who cannot take adequate food/fluids by mouth ❖ Parenteral feeding - parenteral fluids contain water, glucose, amino acids, fatty acids, minerals, & vitamins to meet the individual need for all nutrients. ‒ These fluids are given through the peripheral & central veins. 33
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  MEDICAL FOOD SUPPLEMENTS
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  MEDICAL FOOD SUPPLEMENTS: ModifiedFoods & Beverages • Medical foods are specially formulated products defined and regulated by the FDA as follows: ‒ Medical foods aren’t regular foods. They’re orally administered dietary products formulated for the management of diseases for which specific nutritional requirements have been established. ‒ Medical foods aren’t drugs or dietary supplements and are monitored separately by the FDA. ‒ All efficacy claims for medical foods must be based on recognized scientific principles and sound laboratory and clinical data. ‒ Medical foods must be comprised of components designated as “Generally Regarded as Safe” ‒ Ingredients in medical foods must be listed on the product label in descending order of content. ‒ Medical foods may be used only under medical supervision 35
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  MEDICAL FOOD SUPPLEMENTS: ModifiedFoods & Beverages • Oral intake may be increased by supplementing a balanced diet with between-meal or evening snacks of nutrient- dense foods acceptable to the individual patient • For these snacks, traditional foods such as fruits, crackers, sandwiches, milk shakes, custard or pudding may be served. • For individuals with decreased appetite, increasing nutrient density without actually increasing volume is advised. ‒ For e.g. instead of using skim milk, the patient could receive whole milk with 2 tablespoons of dry milk powder to boost both kcal & protein ‒ Adding peanut butter to toasted bread for breakfast is great for increasing both kcal & protein 37
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  Nutrition Intervention toIncrease Nutrient Density Increasing Energy content • Add butter or margarine to cooked cereals, soups vegetables • Add jam, honey to toasted bread & crackers • Use whole milk or cream with soups, shakes & smoothies • Add yoghurt to shakes and smoothies • Add nut butter to raw veggies, bread or crackers Increasing Protein content • Add powdered milk to any beverage, soup • Add liquid egg substitutes to shakes, soups or veggies • Add nuts, nut butters, chopped meats, cooked eggs, cheese or yoghurt to prepared foods 38
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  Modified Foods andBeverages • Another means to modify foods is to add single nutrients like protein or fiber through the use of modular products. • A CHO modular supplement like Polycose, provides glucose polymers and generally does not alter the taste of food to which it is added. • Protein modular like ProMod or Beneprotein (powder) can be added to both foods & beverages but must be mixed well. ‒ There is a slight change in taste and consistency • Lipid modular supplements like medium-chain triglyceride (MCT) also has a slight change in taste and consistency. ‒ E.g. MCT oil, MCT fuel, MCT power. 1 Tbs gives 6 g of MCT & 50 kcal • Generally, modular foods are not cost-efficient relative to other types of supplements 39
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  Modified Foods andBeverages 40
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  MEDICAL FOOD SUPPLEMENT: CommercialBeverages • Liquid meal replacement formulas may provide a convenient alternative to between-meal snacks. • These products provide 250 to 350 kcal with 7 to 15 g of protein in 250 ml and come in various flavours • They are lactose free and some contain fiber with others being more calorically dense or higher in protein – Examples include Ensure, Boost, Mighty shakes, Resource Health shake, and Carnation instant breakfast • Some of these products are available in liquid form, as puddings or as cereal-type bars • Many of these products are for specific medical conditions like wound healing or diabetes 41
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  Commercial Beverages
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  MEDICAL FOOD SUPPLEMENT: CommercialBeverages • Commercial supplements are popular because of their convenience and also because patients and caregivers may be familiar with them due to marketing via the media • However, acceptability and intake are individual. • Patients receiving oral supplements frequently develop “taste fatigue” a few days after initiation of supplement intake • Note: merely providing supplemental feeding will not increase appetite; in fact many pts complain that extra portions, frequent meals & supplemental snacks are overwhelming & reduce appetite, hence, the need to involve the patient in the decision making
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  MEDICAL FOOD SUPPLEMENT: CommercialBeverages • Provide supplement taste tests to help patient decide which supplement they would prefer to add to their diet • Develop a rotation for snacks or supplements and set portion size goals with the patient to improve acceptance • Regular follow-up and monitoring are necessary in order to coordinate successful interventions and minimize waste associated with unused products
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  DIETARY SUPPLEMENTS: Definition • Aproduct intended for ingestion that, among other requirements, contains a “dietary ingredient” intended to add nutritional value to the diet (FDA, 2022) • The term “dietary ingredients” includes: – Amino acids (e.g., Leucine, isoleucine, tryptophan, glutamine etc) – Vitamins and minerals (e.g., biotin & iron) – Herbs and botanicals (e.g., Ginseng, cinnamon, ginger, garlic etc.) – Dietary substances that are part of the food supply, e.g., enzymes (e.g., lactase) & live microbials (commonly called probiotics) – Concentrate, metabolite, extract, or a combination of any dietary ingredient from the others listed above
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  DIETARY SUPPLEMENTS: Definition • Dietarysupplements come in many forms, including; – Pills, tablets, capsules, powders, liquids, teas etc. • They are intended to be a supplement to the diet • Intended to be taken by mouth; this excludes other routes of administration, such as intranasal, transdermal, & suppository • Benefits of dietary supplements: – Help improve or maintain overall health – Help meet daily requirements of essential nutrients
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  VITAMIN AND MINERAL SUPPLEMENTS •Nutrition assessment may reveal that a patient’s diet is inadequate to meet the standard recommended amounts of essential vitamins and minerals. – Such a patient should be prescribed supplements of the deficient nutrients • Also, many medical conditions interfere with digestion, absorption, or utilization of micronutrients • Therefore, making appropriate, evidence-based recommendations for supplementation of vitamin and minerals is an expected step in nutrition intervention. – E.g. for an osteopenia pt, you would recommend supplementation with Adequate Intake (AI) for calcium according to the age and gender – And provide instructions on appropriate sources of supplements
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  BIOACTIVE SUBSTANCE SUPPLEMENTS • Bioactivesubstances are defined as food substances added to a food product or taken as a supplement that have a specific intended health purpose. – Example, a patient with hyperlipidaemia may be instructed to consume stanol esters as a supplement. The RD would instruct the patient on the amount of stanol esters recommended for the intended reduction of lipid levels – The RD would describe the current products available for purchase and assist the patient with the incorporation of the products into their dietary plan – Other examples of bioactive substance include pro- /prebiotics
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  Examples of Bioactive supplements:stanol esters 50
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  • END OFLECTURE